Lifting the lid on the role of Secretary of State for Health - what really goes on?

Whom did Margaret Thatcher encourage to 'cut the throat' of health reform? And which Secretary of State told the head of Monitor to 'piss off'? Passions run high when it comes to the NHS and our health services, not just from people working to deliver care, but all the way up to those at the very top.

Right now Jeremy Hunt is getting a whole lot of opinions about what to do over the next parliament and how to do it, and we admit we’re part of that deluge. And so we interviewed ten people that have done his job and put their experiences and advice for future holders into a book – and it’s absolutely fascinating.

Take Alan Johnson on problems at Mid Staffs: 'When Mid Stafford broke, Bill Moyes [the Chairman and Chief Executive of Monitor] was trying to tell me that it was his responsibility and not mine [to remove the chair and chief executive of Mid Staffordshire NHS Foundation Trust] – because it was a foundation trust. Now politically it would be very nice if you could get away with it and say, "That’s yours. That’s your can of worms." But I told him, you know, "Piss off. I’m dealing with this."'

Or William Waldegrave’s account of his first week in office: 'When I was appointed, Mrs T [Thatcher] said to me, "Kenneth [Clarke] has stirred them all up, I want you to calm them all down again," and then made it absolutely clear to me that if I wanted to just cut the throat of all these reforms that was fine as far as she was concerned… We had a meeting with her in Number 10, just before she went to Paris, just before she fell. We persuaded her, and it was a matter of persuasion, that the thing made sense and wasn’t just Kenneth trying to cause trouble. But it was clear that she had no particular commitment to it at all.'

But it is far more than an interesting read. For anybody working in health policy, and for ministers in particular, we would argue that it’s an absolutely indispensable read, and each of the insights it contains serves to paint a larger picture of our health system.

For example, that interaction between Alan Johnson and Monitor is just one of many occasions when the Health Secretary has overruled formal structures. Mid Staffs was a foundation trust, it was Monitor’s problem, the law was clear that it had nothing to do with Johnson. And yet it clearly was his business. As he puts it in reference to current structures: 'Parliamentarians aren’t going to put up with being told, "Nothing to do with us. Write to NHS England."'

The lesson of the last 30 years is very clear: behaviour trumps legislation. Or as Stephen Dorrell neatly puts it: 'You can’t legislate away responsibility.'

In the same way, the exchange between Waldegrave and Maragret Thatcher isn’t just historically fascinating but it highlights a number of issues many health secretaries have faced in working with the prime minister.

How much can a PM really grasp about the daily running of the health service? How far should they grasp it anyway? A repeated theme of the interviews is the need to keep the prime mnister well away from the Department of Health.

'When I moved to the Department of Health, I remember one of my special advisers who had moved with me coming into my office and saying: "You’ve got to get Number 10 off our back,"' recalls Patricia Hewitt.

Or to put it in Ken Clarke’s simple and colourful words, it is the health secretary’s job to stop prime ministers 'stamping their little foot' every time a health crisis emerges.

The book is a rich repository of insight and anecdote around the role of the health secretary and its slightly cryptic name, Glaziers and Window Breakers, comes from Virginia Bottomley’s astute observations of the different people to have done the job.

And so going back to the start, what was their advice for the five years ahead? Reform? Legislate? Repeal? No. Take your time – a recurring theme neatly espoused by Frank Dobson: 'I was much criticised because I said to some reporter from the Daily Mirror who came to see me that the first thing I was going to do was sit down and have a good think! Which is out of fashion really isn’t it, to sit down and have a good think? I think they need to do that. Have a good think.' While Jeremy Hunt is not new to the role, perhaps now is nonetheless a good opportunity for him to reflect back on his time so far, before launching in to the detail of what to do next.

Edward is a Policy Fellow at the Health Foundation, www.twitter.com/EdwardDaviesTHF